The Drone Doctors

July 25, 2015Brian Anderson / Motherboard, Vice

A group of US military medical doctors hope to fundamentally change an intense work culture within the American drone program, where the physical and mental toll of near round-the-clock remote warfare can be suffocating for pilots, sensor operators, and analysts, and stifling to the Air Force, as it struggles to train and retain drone personnel.

(July 17, 2015) -- When Adam Patterson watched live video feeds from US surveillance and combat drones hanging over the Middle East and Northern Africa between 2006 and 2009, it was like he was in a swimming pool and someone was holding his head underwater.

"You're not really thinking at that time, 'Why am I in this pool, and why is this individual here with me, holding my head down?'" Patterson told me. "You're thinking, 'How do I get out of here?' You're thinking not so much strategically, but tactically. You're thinking about the task at hand, not so much what is surrounding it. I was in that mode, and that probably helped my mental health."

Patterson, now 37, was a member of US Special Operations in Iraq and Afghanistan before he took a gig as a drone analyst for a private military contractor. For two years, Patterson would get up in the morning and walk to a steel building at the edge of an American military base in Iraq.

The building was festooned with all sorts of satellite dishes and communications antennas and surrounded by military vehicles -- the tactical operations center, where Patterson worked at the brigade level.

The battle rhythm ebbed and flowed. "Sometimes it was pedal to the metal," he said. "Sometimes it wasn't." It would get slow around Ramadan. Sometimes Patterson would go days just staring at a video feed of a house, waiting for any sign of activity to report up the chain of command. Other times he would watch a quarter of a city block incinerate, struck by a Hellfire missile fired from an American drone.

The key thing that made it easier for him to sleep at night as a drone analyst, he said, is that he transitioned into that line of work right out of the military. He was already in battle mode. Mentally, he was suited for the job. Sometimes when he watched video of people clearly dying in the wake of an aerial strike, he would laugh.

"Eh, we're at war," he'd tell himself. "These are realities of war, and we just need to get over them as Americans. It's just what happened. It comes with the territory."

If it were today, maybe Patterson would've been told to take a knee. It's a resting order as old as war itself, and has become the mantra for a group of US military medical doctors who hope to fundamentally change an intense work culture within the American drone program, where the physical and mental toll of near round-the-clock remote warfare can be suffocating for pilots, sensor operators, and analysts, and stifling to the Air Force, as it struggles to train and retain drone personnel.

The 432nd Wing Human Performance Team operates out of Creech Air Force Base, a desert outpost roughly 45 miles northwest of Las Vegas, where the US carries out reconnaissance and strike missions throughout the Middle East and Northern Africa using remotely-piloted aircraft like the MQ-1 Predator and MQ-9 Reaper.

The Human Performance Team, or HPT, is comprised of an operational psychologist and physiologist, as well as a flight surgeon and a pair of chaplains and chaplain assistants. They are each given top-secret clearance so they can meet with drone personnel at Creech who are fatigued or troubled by occupational burnout, an extended response to chronic job-related stress.

At just seven strong, with members rotating in and out in cycles, the HPT is lean -- a sticking point for critics like Patterson, who question whether the HPT is enough to address the true scope of the problem.

"So the Air Force has this task force developed," said Patterson, who lives in Georgia with his wife and kid. "They really don't care about drone pilots. They're just doing it to say they did it. They're forming this task force just to say they've formed a task force."

There are psychologists and physiologists stationed at US military bases around the world, but the HPT, now in its fourth year, is the first dedicated interdisciplinary outfit tasked with fostering physical, psychological, emotional, intellectual, and spiritual well being among Air Force personnel working with remotely-piloted aircraft in combat. It was formed just a year after US drone strikes peaked in Pakistan in 2010, among other places.

Why? A 2011 Pentagon study, commissioned by the Air Force, found that nearly 30 percent of drone pilots reported suffering from high levels of fatigue. The Air Force did not consider that 30 percent figure to be a worrisome level of stress at the time, but in a pre-HPT world the pilots really had no one to talk to other than themselves. Seventeen percent of active-duty drone personnel surveyed in the study were thought to be "clinically distressed."

The HPT is a sort of pilot study that has spurred bases abroad housing US drone operators to bring on doctors to care for particularly exhausted or stressed individuals. The Creech doctors spoke on condition of anonymity due to the sensitivity of their work. "Our days revolve around airmen and their lives," one team member said.

***
Technology has brought modern warfare home, with drone pilots and operators stationed at a handful of bases, including Creech, throughout the American West. But being so far removed from the battlefield hasn't necessarily lightened the psychic burden.

"The mental stress of combat is not decreased with distance," one HPT member told me.

The medicine of war has had to adjust accordingly. The HPT might tell you to take a knee, but meanwhile researchers have gone so far as to propose a Siri-like user interface to quell the psychological effects of fatigue and burnout, including anxiety, alcohol abuse, depression, post-traumatic stress, and suicidal ideation, as noted in the GQ profile of Brandon Bryant, one of the most outspoken former US drone pilots. The interface would function as a kind of virtual co-pilot, anthropomorphizing the drone in a way that would allow crews to deflect the gravity and blame of a mission.

Col. Kent McDonald, who co-authored the 2011 Pentagon study, told NPR that the battle rhythm of drone warfare, in which pilots and sensor operators must sometimes observe potential targets for weeks before, during, and after they pull the trigger, presents an "existential crisis."

Heather Linebaugh, an Air Force drone veteran, can't unsee a man with a shattered leg bleeding out after a drone strike. Bryant, who also appeared in an episode of VICE on HBO, has taken to writing poetry featuring dead soldiers in seas of blood.

"It is OK to take a knee if needed"
For the HPT, the goal is to build a comprehensive, proactive push against "burnout," a word that the team said is perhaps misused as a term to describe a certain range of experiences and symptoms.

"It is a term that has been so widely used that it is difficult to find an agreed-upon definition that accurately and fully grasps the complexities and dynamics of all that burnout means and represents," the HPT said.

For research purposes, the team chose to stick to the definition of "burnout" first put forward in 1998 by occupational psychologists Christina Maslach and Julie Goldberg: "a type of prolonged response to chronic emotional and interpersonal stressors on the job.

It is an individual stress experience embedded in a context of complex social relationships, and it involves the person's conception of both self and others. More specifically, burnout is defined as a psychological syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment."

The problem begets itself. The HPT has found that as drone personnel climb in rank while doing shift work, with rotations going 24/7, the higher their rates of fatigue and signs of burnout.

By nature, the sort of personality Creech attracts in its drone personnel, who number around 1,000, is often extremely motivated and driven, according to the HPT. That can make it a struggle to ensure pilots and sensor operators are taking good care of themselves, including spending enough time out of the trailer, away from the screens.

The HPT wants to rein in this always-on, in-garrison mindset. It's OK to take time off, the team tells drone personnel. It's about recognizing fatigue and burnout as "one of our vulnerabilities," one of the team members said, and stressing to individuals the importance of not running yourself into the ground. "It is OK to take a knee if needed."

At Creech, normal flying shifts run eight hours. Pilots and sensor operators sit side-by-side in cockpit chairs inside air-conditioned trailers, where they watch multiple live video feeds from so-called hunter-killer drones like the Predator and Reaper.

They type over encrypted chat with intelligence analysts stationed abroad at bases like Patterson's, and also communicate over headphones. They both scan landscapes, cities, and villages in parts of Pakistan, Afghanistan, and Yemen. The pilot controls the movement of the aircraft with a joystick, while the sensor operator controls its cameras and also guides its missiles.

They run on a five, one, and two schedule, meaning Creech drone personnel fly five days a week. Personnel have one day open for running errands, doing volunteer work, or putting in some extra training. They have a two-day weekend. It's an eight-day week, meaning they can take weekends Saturday through Sunday, or Monday through Tuesday, and so on.

Pilots and sensor operators do sometimes work up to 12 hours per day, but most do not fly that long, according to Sgt. Cecilio M. Ricardo Jr., a Creech public affairs officer. Ricardo said crews are also required to clock 12 hours of uninterrupted rest prior to every flight session.

"Cognitively it's very demanding," one HPT member said. Pilots and operators must shift their eyes and focus across multiple screens and data streams. "Remotely-piloted aircraft personnel are stressed," an HPT member told me, "but they are not stressed out." Overall, most of Creech's drone personnel manage themselves "very well."

Prior to starting missions all pilots and sensor operators at Creech must self-identify their physical, mental, and emotional preparedness to perform at their peak. As operators carry out missions, the HPT constantly optimizes basic human factors. The drone doctors adjust the pilot's and operator's seats, lighting, screen resolution, and other ergonomics.

All the while, the team works with Creech brass as well as those "on the front line" -- the people sitting in those pilot seats -- so that they are capable of identifying when someone starts to trail off. Is he anxious? Depressed? Falling asleep? Drinking heavily? Suicidal?

The team tailors medical prognoses on a case by case basis. An individual going through difficulties at home might first talk with the HPT psychologist before being referred to the physiologist once it's realized the person's issues have more to do with sleep management, not mental health, a team member said.

Or an individual seeking the privileged communication of the chaplain, or who might have questions about combat and faith, is encouraged to talk with the psychologist after the chaplain identifies markers of mental stress.

Every operator's health is tracked tracked per the Air Force's Operational Risk Management program, and an individual might be given temporary DNIF (Duty Not to Include Flying) status as the HPT helps pull him back from the edge. Col. Jim Cluff, commander of the 432nd Wing at Creech, said the team prevented 13 suicides on base in 2014.

That same year, a Government Accountability Office report found that Air Force drone pilots were bummed on what they felt was a stigma surrounding their work. Four of 10 survey groups in the GAO study did report that that negative perception was beginning to improve, and also that the flying service was working to root out undue stress, which can lead to burnout and post-traumatic stress later in life.

But despite the Air Force's efforts to make drone scheduling and working conditions better tuned for group and individual well being, nine of the 10 focus groups said the stress put on their relationships with family and friends was intensified by marathon days spent inside air-conditioned trailers, remotely engaged in a shadow war thousands of miles away.

Drone pilots and sensor operators at Creech contend with three key stressors, according to the HPT. In the team's most recent study, 60 percent of drone personnel said being under-manned was the top source of stress.

"The truth is, we do our mission very well and because of that we are in high demand," the team said, referring to drone operators it supports. "That demand has outpaced manning. It is the top priority for our community and a recent response to this was a reduction in combat air patrols," the team added, objecting to a recent New York Times story about the Air Force cutting the number of combat drone flights because of stressed, burned out pilots and operators. The Air Force didn't cut flights explicitly because of stress. "It's simple math," a HPT member said.

The second major stress point is the shift work. A 2014 study by researchers at the US Air Force School of Aerospace Medicine at Wright-Patterson Air Force Base surveyed over 1,000 operators across 18 different drone squadrons in the US, who often reported working 50 or more hours per week.

Ricardo said the team shift work at Creech is challenging, particularly for drone personnel with a spouse or children. "If there were a way to conduct these operations without doing shift work," the team said, "there would be a significant improvement in overall health and wellbeing for this community."

If there's one place these stressors intersect, it's in everyday relationships. That's why the HPT puts special emphasis on what's called "transitioning." Creech pilots are deployed "in place," which means they must switch from combat mode to home life in just a matter of hours, not days.

The Air Force Times reported about 30 percent of airmen -- the majority are men -- feel their relationships worsened after they were assigned to Creech. It can be a jarring thing, going from the battlefield to the dinner table with family in the space of an afternoon.

"If I'm a soldier on the ground and someone is trying to kill me, I don't have to think too much about how I'm going to respond to that," a HPT member said. "Remote combat requires me to think differently about what we are doing and to understand what it means to be in combat halfway around the world. There have been reports of our operators approaching their work as though it were a videogame. Nothing could be further from the truth."

***
Inside the tactical operations center, Patterson sat at a long table with three or four other people. They were each seated in front of a trio of screens positioned in a C shape. For eight hours a day they would monitor these feeds, which streamed a mix of footage from Predators and Reapers as well as smaller drones on more locally-focused missions, perhaps patrolling the perimeter of the base. They worked on three shifts -- 8-4, 4-12, and 12-8 -- around the clock.

"Alright, my butt is occupying this chair," Patterson would tell himself. "I will do the best I possibly can for these eight hours, and do exactly what they want me to do and make as few mistakes as possible.'

Patterson said he had it easy, and that it was more difficult for the active-duty personnel who filled out that room at the tactical operations center. His contract stated explicitly that he would work eight hours a day, seven days a week, and get a set amount of leave every few months.

"Everything was real rigid, but not so much for the soldiers," he told me. He said it was not uncommon for them to work 16 or even 18 hours days, then go sleep for a bit before coming right back.

They sat in the same room, although it's unclear exactly what went into the active-duty personnel's intelligence gathering. They would sit at Patterson's back, and chat with pilots and sensor operators at Creech or at Davis-Monathan Air Force Base near Tucson, Arizona.

"'Look at this, go over here, stop there,'" Patterson said, recalling the chatter he'd overhear. "'Let's check out this area for a little bit. Oh, there's troops in contact at this grid, could you go over there?' And they'd say, 'Oh, our mission states we can't do that,' or, 'Yes we will.'"

When his shift was over, Patterson would brief the relieving contractor analyst crew: "OK, this [drone] is looking at this, this one at this, this one's going over here, this one's on its way back, another is going out there to relieve this one."

"I wasn't pulling the trigger or pushing the button to kill anybody. But I was observing it, and somehow endorsing it"

"We had to know what each one was doing," he told me. "It was almost like a video game. I didn't have time, or really the need at that time to question anything that I was doing, or anything I was participating in. Granted, I wasn't pulling the trigger or pushing the button to kill anybody. But I was observing it, and somehow endorsing it."

Patterson wishes the treatment of former drone personnel, active-duty or contractor, who actually grapple with the physical and mental demons of burnout and post-traumatic stress were as easy as sending out a psychologist or physiologist to prescribe everyone prescription drug cocktails.

"I wouldn't endorse that," he said. What he does endorse, besides the US ending all its combat operations, is the use of medical cannabis, psychedelic mushrooms, and ayahuasca to heal the lasting psychic wounds of war, including suicide.

The Air Force, Patterson said, created the Human Performance Team "so they can check the block, and so that people are talking about it. Some of these doctors might really care. I think they might really be concerned with some of the individuals inside the program.

They might legitimately care, they might legitimately want to do something about it. And they may be doing that, but the cost is too high to help out these soldiers and contractors or whoever is working on these programs."

Talking about his experiences, about what he thinks is right and wrong, still helps Patterson. "That's my therapy," he said, "rather than taking any drugs."

The other day, when he dropped by the local Veterans Affairs office to pick up a special card that earns veterans discounts at stores like Home Depot, Patterson had to grit and bear an over-eager VA staffer trying to sell him on a benefits package.

"Oh, you were in war," the VA staffer said. "Are you OK? Is your back alright? You walking straight? Everything fine? Any aches or pains?"

This went on for a half hour, Patterson said. The guy was trying to twist his arm, and get him to submit.

"Nothing is wrong with me," Patterson told the staffer. "Everything is fine. I learned a lot of lessons, but mentally and physically I'm fine."

Modern Medicine is a series on Motherboard about how health care and medical technology can move forward so rapidly while still being stuck in the past.

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